Provider Demographics
NPI:1861733800
Name:STEVIE WILSON, P.C.
Entity type:Organization
Organization Name:STEVIE WILSON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-420-1658
Mailing Address - Street 1:9501 S I 35 SERVICE RD
Mailing Address - Street 2:907
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3140
Mailing Address - Country:US
Mailing Address - Phone:405-420-1658
Mailing Address - Fax:
Practice Address - Street 1:1601 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 6
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6359
Practice Address - Country:US
Practice Address - Phone:405-420-1658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty